I recently posted a blog post about Ritalin. Although it often ‘gets a bad rap’, it’s a medication which can still be very helpful for ADD/ADHD. Of course, the newer medicines (which are long acting) seem to be better for a good treatment response, though Ritalin can still play a role.
In that article, I mentioned the concept of taking Ritalin with Concerta – i.e. together. When someone commented on that post, I realized that I should share more specifics and details about how this can be done safely and effectively.

For background information, you can reference these previous blog posts about Ritalin and Concerta:

• The article on Ritalin can be found here
• An article on Concerta can be found here
• My popular article on how to dose Concerta effectively can be found here

The Concept Behind Concerta’s Formulation:

Concerta, as the first long acting ADHD medication, was developed using a fascinating approach. The scientists put kids with ADHD into an ‘analogue classroom’ – meaning a research environment which simulates a school classroom. So, children were given tasks which would occur in a regular school day, and they were monitored by experts in  ADHD. These kids were given an IV line, which allowed for the researchers to draw blood HOURLY, so they could establish the blood levels of the medication throughout the day – and they could correlate the blood levels of the medication to the behavior (and ADHD symptoms) observed throughout the day.

The researchers tried different approaches with the medication. The children were given short acting Methylphenidate (i.e. the medicine in Ritalin). By giving different amounts of medicine on a very frequent basis, they were able to create different levels of blood concentration through the day.This was called a ‘sipping study’. They were giving little bits of Ritalin throughout the day, very frequently – like you would ‘sip’ a soda. By monitoring the blood levels, they created different ‘profiles’ of blood concentration.

The first concentration approach was: FLAT. This meant that the medicine was given to reach a ‘plateau’ level of blood concentration, and the rest of the doses throughout the day were set up to maintain that level of concentration in the blood.

The second concentration approach was: ASCENDING. This meant that the doses were set up to increase the blood concentration slightly, hour by hour throughout the day.

The third concentration approach was: DESCENDING. This meant that the doses were given to create an initial spike up, and then the blood concentration would drop through the course of the day.

Guess which concentration approach was proven to be most helpful in controlling symptoms of ADHD through the course of the day?

ASCENDING worked best.

Thus, Concerta was developed to create an ascending profile of blood concentration throughout the day. This means that when the 22% of immediate release methylphenidate is absorbed, it creates a spike in blood concentration in the first hour, and then the Concerta is formulated to increase the concentration of methylphenidate in the blood, so that hour by hour, there is more medicine in the system. The concentration level increases for the first approximately 8 hours of the day, and then it begins its drop. It thus gives approximately 12 hours of symptom control.

Why does an ascending profile seem to work well?

The researchers suggested that there is ‘acute tachyphylaxis’, or ‘acute tolerance’. They suggest that if the blood level of the medication is the same at 11 am as it was at 10 am, the brain is becoming tolerant to that level of medicine that quickly, and it is less effective at 11 am as it was at 10 am. Concerta was formulated to overcome this, by having slightly higher concentrations of medicine throughout the day. Under the theory of acute tachyphylaxis, the system of ‘tolerance’ to the medication would reset itself each night, as the medicine wears out of the system.

Back to combining Concerta with Ritalin:

Explaining the science of Concerta was important to explain the rationale for what I’ll say next about combining Ritalin (or short acting Methylphenidate) with Concerta.

It is important, because if the ‘ascending profile’ theory is correct – then adding Ritalin to Concerta first thing in the morning will ruin the unique formulation of Concerta, and essentially ruin the ascending profile of concentration.
In other words – if Concerta is formulated so that a certain amount of it is immediate release (i.e. 22%), then the rest of the pill supports that to create the ascending profile. If one takes a short acting Ritalin with the Concerta in the morning – then the ascending concentration profile in the blood becomes a descending profile, because the initial spike will be so big, that it would throw off the concentration profile for the rest of the day.

So, the ‘Concerta purists’ (if you could call them that) would say that you should never add regular Ritalin to Concerta first thing in the morning. If someone isn’t getting a strong enough response first thing in the morning, then they need a higher dose of Concerta.

These ‘Concerta purists’ would be fine with adding regular Ritalin to Concerta at the end of the day – if a little ‘bump’ is needed to make the medicine last longer. For example – if the Concerta lasts for 12 hours, but on certain nights, night school classes are taken, adding a 10 mg Ritalin tablet at the end of the day on those nights would be completely reasonable.

So Why Do Some Doctors Add Ritalin To Concerta In the Morning?

Despite what the researchers may say, and what studies may show in those circumstances, each person is an individual, and people have different responses to medication.

In my years of clinical experience, do I believe the ‘ascending profile’ story of Concerta to be 100% true and accurate for everyone?  No – I don’t. I have seen people for whom Concerta was a miracle medicine, and I have seen people for whom Concerta didn’t work at all. I have certainly (and regularly) seen people who add Ritalin to Concerta at the end of the day.

Concerta and Ritalin together in the morning? Not generally my practice, though I have colleagues who have done this with reported success.

The most important point for YOU:

Your treatment needs to be individualized.

I hope that you can discuss with your doctor the strategies which may help you to optimize your medication treatment for ADHD. Heck – if you’re going to take medication for ADHD, you want it to work the best it can, right?
Combining Ritalin and Concerta may just be an ‘advanced strategy’ for managing your medications that will help you and your doctor to find the right treatment.

A final point about safety: When combining Concerta and Ritalin, remember that these are the same medication, and that higher doses of methylphenidate can cause more side effects, particularly cardiovascular ones – i.e. increase blood pressure, or increase heart rate. Be sure to talk to your doctor about the ‘total daily dose’ to make sure that it is safe for you.

Please share your experiences and thoughts below.

All the best,

Dr. Kenny

p.s. I have just put together a new video on how to use ADHD Medications both safely and effectively. You can get access to that video by visiting here.

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